Norbury Hall

Updated 24 June 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Our inspection was completed by one inspector, a specialist nurse advisor and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Norbury Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced. The inspection activity all took place on 10 May 2022.

What we did before the inspection

We reviewed the information we had received about the service since they registered with us, including any statutory notifications received. We reviewed the provider information return. This is information providers are required to send us with key information about their service, what they do well and improvements they plan to make. We used all of this information to plan our inspection

During the inspection

We spoke with six people using the service and five relatives. We carried out observations of interactions between people and staff. We spoke with the registered manager, deputy manager, three support workers, two activities officers. We also spoke with four health and social care professionals. We reviewed a range of records. These included care and staff records and records relating to the management of the service.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We also received feedback from the local authority who recently inspected the service.

Updated 24 June 2022

About the service

Norbury Hall is a residential home for up to 81 older people, many of whom were living with dementia. At the time of the inspection 75 people were receiving personal and nursing care.

People’s experience of using this service and what we found

The registered manager was experienced and understood their role and responsibilities well overall, as did staff. The registered manager engaged well with people using the service, relatives and staff and staff felt well supported by them. The registered manager notified CQC of significant events, such as allegations of abuse, as required by law and understood their legal responsibility to be open and honest with people when something goes wrong.

Risks relating to people’s care were well managed, although risks relating to pressure ulcers for one person could be improved as their pressure mattress was not always at the correct settings. There were enough staff to support people safely and the provider had invested significantly to improve staffing numbers since our last inspection. Recruitment was robust and ongoing. Staff received training in infection control, including the safe use of personal protective equipment (PPE), to reduce the risk of COVID-19 transmission. People received the right support in relation to their medicines and the registered manager oversaw this. The premises were maintained safely with regular checks.

Staff received the training and support they needed to understand and meet people’s needs with specialist training available. People were supported to maintain their health and to attend appointments with professionals involved in their care. People received food and drink of their choice, meeting their dietary and cultural needs and preferences, with snacks available outside of mealtimes. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People liked the staff who supported them and were comfortable in their presence and staff knew people well. People were encouraged to be involved in their care as much as they liked. Staff treated people with dignity and respect and protected people’s confidential information. Staff received training in equality and diversity and understood people’s differences. People’s care plans were based on their individual needs and preferences and were kept up to date. The registered manager investigated and responded to any concerns or complaints in line with their policy and people had confidence in how they would respond.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection and update

The last rating for this service was requires improvement (published August 2019) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations. At our last inspection we recommended that people’s nutritional outcomes should be improved and also that food hygiene should be improved. At this inspection we found that the provider had acted on our recommendations and had made improvements.

Why we inspected

This inspection was prompted due to concerns raised by the London Ambulance Service (LAS) regarding restraint and to check improvements made since the last inspection. We found the issues raised by the LAS were no longer of concern and the service had improved since our last inspection.

Follow up

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.